New Client Intake Form

Thank you for taking the time to fillout the new client intake form. The information you provide will help me serve you to the best of my abilities. Please fill it out each item the best you can. Any questions you may have can all be answered during out visits.

Estimated Due Date
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Month
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Day Year

Mother's Name
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First Name Last Name

Mother's Phone Number
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Area Code Phone Number

Partner's Name

First Name Last Name

Partner's Phone Number

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Area Code Phone Number

Address
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Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

E-mail
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Additional Phone Number

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Area Code Phone Number

Where are you delivering?
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Your Doctor/Midwife
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Prenatal tests? Please list:

Are you high risk?
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Yes No

Reason?

Your childbirth education history:
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Nutrition Childbirth prep Breastfeeding Infant care CPR Other I haven't taken any CBE classes yet, but I intend to. I haven't taken any CBE classes and I don't intend to.

Please specify the childbirth education you have or that you intend to take.

On a scale of 1 to 10, how painful do you think birth will be for you?

What has influenced your expectations of labor? (Relatives? Friends? TV?)

What fears or concerns do you have around labor and delivery?

What kind of support do you expect from your Doula and partner?

In general, where do you feel tension in your body?

How do you regain calm during times of stress?

What kinds of things do you find helpful in times of stress or pain, i.e. cheering you on, massage, being left alone

For Partner: What strategies do you have for calming her down? How confident are you in your ability to do that?

What gives you confidence?

Are you having any major life stresses right now?

Personal or family history of depression or other mental disorders?

Yes No

If yes, please describe briefly.

Religious affiliation/needs during labor?

Birth Preferences Information

This section is about what you would like to have happen during your labor and delievery. You may not have started thinking about or heard about some of the options listed here. That's OK. We can go over anything you are unsure of. This list can also be used to start the conversation with your provider.

During Labor I would like:

To dim the lights To bring music To wear my own clothes during labor and delivery To take pictures and/or film during labor and delivery Use aromatherapy

Please specify your aromatherapy scents preferences:

Labor

I would like the option of returning home if I am not in active labor.

Once I am admitted, I would like:

My partner and Doula to be allowed to stay with me at all times. Only my practitioner, nurse and guests present i.e., no residents, medical students or other hospital personnel. To wear my contact lenses, as long as I do not need a c-section. To eat if I wish to. To stay hydrated by drinking clear fluids instead of having an IV. Decline the Hep/Saline Lock. To walk and move around as I choose.

As long as the baby and I are doing fine, I would like:

To have intermittent rather than continuous electronic fetal monitoring. To be allowed to progress free of stringent time limits. To follow a natural means of progression (no augmentation of labor via Pitocin or amniotomy without discussion). To allow for spontaneous rupture of membranes

If they are available, I would like to try:

A birthing stool A squatting bar A birthing pool/tub A birth ball Other

Specify "Other"

When it is time to push, I would like to:

Do so instinctively. Be coached on when to push and for how long. Not sure.

I would like to try and/or I am open to trying the following positions for pushing (and birth):

Semi-reclining Side-lying position. Squatting. Hands and knees Whatever feels right at the time.

To view the birth using a mirror. To touch my baby's head as it crowns. The room to be as quiet as possible. To risk a tear rather than have an episiotomy. To catch/pull my baby out and onto my chest immediately.

After birth, I would like:

To hold my baby right away, putting off any procedures that are not urgent To wait until the umbilical cord stops pulsating before it is clamped and cut. My partner to cut the umbilical cord. To breastfeed as soon as possible. Within the "Golden Hour" if possible. Not to get routine oxytocin (Pitocin) after I deliver the placenta.

Cesarean Section

If I have a cesarean section, I would like:

To be allowed to go into spontaneous labor (if possible). My partner present at all times during the operation. My Doula present at all times during the operation (if possible). I would like a play-by-play of what is happening. The screen lowered a bit so I can see my baby coming out. I would like to be skin to skin with baby during the remainder of the procedure. I would like arms free to touch my baby. The baby given to my partner as soon as s/he is dried (as long as s/he is in good health. To breastfeed my baby in the recovery room.

Postpartum

This section covers your preferences during the postpartum period. This is a good time to start thinking about the kind of parent you invision you'll become.

After delivery, I would like:

All newborn procedures to take place in my or my partner's presence. My partner to stay with the baby at all times if I cannot be there. My partner to stay with me. My partner to stay with baby and Doula to stay with me. (Such as post c-section.)

24-hour rooming-in with my baby. To make my decision later depending on how I am feeling.

For a boy:

I plan to leave him intact. I plan to have him circumcised.

For baby:

Delay injection of Vitamin K until after baby has had a chance to latch/breastfeed. Decline Vitamin K. Delay use of Erythromycin or other eye salve. Decline Erythromycin. Decline injection of Hep B vaccine.

Transition Into Parenthood

Do you feel you have community for support in the immediate area?

What are you most looking forward to about being a parent?

What fears do you have about early parenthood?

Do you have any concerns about your (or your partner's) ability to breastfeed?